Mixed Methods in Health Promotion Research

SHE Summer School 2014 Mixed Methods in Health Promotion Research Evaluating effects of HP programs in complex systems

SHE Summer School 2014 Mixed Methods in Health Promotion Research Evaluating effects of HP programs in complex systems http://fr.padlet.com/demjour/p99dcpczoqqz

Health Promotion Research applied nature. producing knowledge about the conditions, practices and processes that makes changes possible research process should be health promoting itself Potvin and Jones (2010) The notion of Health Promotion Research raises important epistemological questions

Health Promotion Research Defining Health Promotion Research Philosophical assumptions (paradigms) Strategies of inquiry Research methods Creswell 2009

Health Promotion Research Paradigms Positivism (identify and assess the causes that influence outcomes) Social constructivism (a research focused on what people say, on the meaning they have of their experiences) Participatory (research inquiry needs to be intertwined with politics and a political agenda) Pragmatic (what works)

Health Promotion Research Paradigms Positivism Social constructivism Participatory Pragmatic Question 1 : A single paradigm for health promotion research?

Health Promotion Research Strategies of inquiry Quantitative strategies Qualitative strategies Mixed-methods strategies Question 2: A specific set of research strategies for health promotion research?

Health Promotion Research Methods Question Data collection Data analysis Interpretation Write-up Validation Ethics Question 3: A specific set of research methods for health promotion research?

Health Promotion: a Field of Practices Unlike others research fields (such as social psychology, sociology ) HPR is not rooted in a particular theoretical and methodological framework. The research is also about understanding practices rather than testing theories

Health Promotion: a Field of Practices In HP, what is essential is not the framework but rather the practices/action and the people (individual, groups and institutions stakeholders) who carry them out. The researcher can t be outside of the action but is essentially an actor within it. A neutral position is not an option.

Health Promotion Research Research on Health Promotion Ethnography Psychology Sociology Epidemiology

Health Promotion Research The research has two goals that must be addressed: - The creation of new knowledge epistemic -That of social transformation transformative Health Promotion Research is epistemic and transformative.

Health Promotion Research One must ask then whether these two goals are compatible in research. This kind of tension between two different aims is not exclusive to HPR. It also operates in fields of research such as: political science, engineering science, social research and educational research In all of these sciences research must firstly address themselves to actual practices.

Health Promotion Research Four key points: Position of the researcher Willing engagement with complexity Multidisciplinary approach Ethical framework

Health Promotion Research 1. Position of the researcher: where the researcher places himself? In HPR this is never a fixed position but is constantly being reconstructed in relation to the research goals, the context and other factors that may need to be considered. 2. A willing engagement with complexity with no straining after artificial simplicity or methodological reductionism. 3. A multidisciplinary approach must be taken in order take account of this complexity at different levels which operate within HP. 4. A clear ethical framework referred to HP

A coherent research program. Millefeuille Mayonnaise

SHE Summer School 2014 Mixed Methods in Health Promotion Research Evaluating effects of HP programs in complex systems

Strategies of inquiry: three types of configuration In the first configuration, the programme evaluation context requires intensive information, has low availability of credible information and has a highly open programme system. qualitative methods. In the second configuration, the evaluation context requires extensive, precise information, has high availability of credible information and has a closed programme system. quantitative approach. The third configuration concerns programme evaluation contexts requiring information that is both intensive and extensive, that provide high access to some information but low access to other information and have the characteristics of both open and closed systems. mixed methods Chen, 1997

Mixed methods research Creswell and Plano Clark (2007) defined mixed methods research as the combination of quantitative and qualitative approaches that provide a better understanding of research problems than either approach alone.

Four major types of interaction triangulation: obtain a more complete understanding of a phenomenon from two databases, to corroborate results from different methods or to compare multiple levels within a system; embedded: one data set provides a supportive, secondary role in a study based primarily on the other data type, its purpose is to address different questions that call for different methods or to enhance an experiment by improving recruitment procedures, examining the intervention process or explaining reactions to participation; explanatory: a two-phase mixed methods design where qualitative data helps to explain or build upon initial quantitative results; exploratory: the results of the first method (qualitative) help to develop or form the basis of the second method (quantitative).

Three questions linked to the choice of a mixed methods research design the level of interaction between the quantitative and qualitative strands, the priority of the strands their timing.

Two main approaches Merging the data that are collected concurrently using either side-by-side comparison, joint display (i.e. a cross table) or data transformation (quantitising - data collected through qualitative methods, converted into numerical codes to be statistically analysed - or qualitising - data collected with a quantitative method, and converted into narrative data analysed qualitatively ). Connecting the data that are collected sequentially.

A example from France A theory-driven approach to evaluation. This approach is not the global conceptual scheme of the grand theorists, but more prosaic theories that are concerned with how human organizations work and how social problems are generated [ ]. What we are strongly advocating is the necessity for theorizing, for constructing plausible and defensible models of how programmes can be expected to work before evaluating them. Chen & Rossi, 1983

Theory-of-change model of a health promotion intervention in school setting Teacher training Institutional lobbying Intermediate-term outcomes Enhancement of children s health knowledge, attitudes and skills Short-term outcomes Development of relevant teachers HP practices Intermediate-term outcomes Enhancement of children s and teachers school well-being Impact Enhancement of children s social, emotional and physical health Intermediate-term outcomes Enhancement of the relationships between school and families Short-term outcomes Development of a HP school s environment School team support Resources and tools Pommier et al. 2010

Two main sets of evaluation questions What are the factors that allow the school community to develop a health promotion approach? How do the strategies developed through the intervention influence the development of teachers health promotion practices and the schools health promotion environment? How do these practices affect well-being in the schools? What is the influence of the intervention on the children s perceived life skills?

Data are collected at the national, regional, schools and children levels. At the national level, documents related to the implementation of the intervention and researchers memos were collected over the three years. At the regional level, documents related to the implementation of the regional intervention were gathered during the three years and focus groups were organised with the regional teams at the end of the third year. Regional teams also filled in a questionnaire to describe how each school received the intervention. At the school level, individual and collective questionnaires were filled in by teachers and school teams. Contextual data were gathered on school context (i.e. size of the school, number of teachers, of pupils, socio-demographic data, etc.). Focus groups were also organised with selected school teams during the last year of follow up. Children from 8 to 11 years old filled in questionnaires focusing on their perception of their life in their school and of their life skills. Parents were also invited to fill in a questionnaire on how they perceived the life in their children s school, their relationships with it and their involvement in the school s activities.

The design An embedded design: QUAN(qual). The evaluation questions focus on quantitative data to measure changes and qualitative data plays a support role in exploring health promotion practices and contexts to better understand the QUAN data. Data are collected concurrently: quantitative numerical data are collected from questionnaires and forms and qualitative data (text data, transcripts and memos) from open-ended questions included in questionnaires, forms and from semi-directed interviews and focus groups.

The design The data are analysed using quantitative (univariate, multivariate and multilevel analysis) and qualitative analysis (content analysis). Qualitative data were quantitised in order to be included in the quantitative analysis. The interpretation is quantitative, qualitative and combined where the quantitative results are clarified by the qualitative results, in order to generalize the findings, predict and interpret theory Qualitative and quantitative methods are mixed throughout all phases of the project from the design stage through data collection to data interpretation.

Three examples Factors and their interactions that may influence the regional teams in implementing sustainable health promotion interventions for school staff and communities qualitative approach followed by quantitisation Impact of the program on teachers health promotion practices quantitative approaches completed by qualitative data sources

Teachers views of their role in HP Views % teachers Group 1 Non respondents 1% Group 2 Not teachers role 3% Group 3 Mostly parents' role 10% Group 4 Doctors and nurses first 7% Group 5 HE as a part of teacher s domain 19% Group 6 HE as a part of teacher s domain in a global approach of HE 43% Group 7 Militants of HE 17% Hierarchical clustering dendrogram Simar et al. 2010

Collective work at the school level A qualitative approach based on A four years work With a group of teachers, principals, advisors, inspectors and researchers On written sources, i.e. school projects, teachers and students documents, emails, minutes of meetings, letters Collected in 22 schools A report Interviews and focus group with stake holders in order to check the relevance of the analysis Merini et al. 2011

Contribution of school variables to Health Determinants (example: school climate) Student 92% Teacher 7% School 1% Multilevel analysis Jourdan 2010

A QUAN(qual) embedded MM design Well-being of children at school Self administrated and user friendly n=945 8-11 ys-old 19 schools Data collection QUAN Procedures - Questionnaires - Forms qual Data analysis QUAN Procedures -Statistical procedures: descriptive, univariate analysis -Scores construction qual SAS n=41 8-11 ys-old 2 rural schools Procedures - Focus group - Photovoice - Mapping Procedures - Qualitative directed content analysis Nvivo 8 Child-focused and participative approach 40

SHE Summer School 2014 Mixed Methods in Health Promotion Research Evaluating effects of HP programs in complex systems http://fr.padlet.com/demjour/p99dcpczoqqz